Mortality Trends During a Program That Publicly Reported Hospital Performance

Background. It is unclear whether publicly reporting hospitals’ risk-adjusted mortality leads to improvements in outcomes. Objectives. To examine mortality trends during a period (1991–1997) when the Cleveland Health Quality Choice program was operational. Research Design. Time series. Subjects. Medicare patients hospitalized with acute myocardial infarction (AMI; n = 10,439), congestive heart failure (CHF; n = 23,505), gastrointestinal hemorrhage (GIH; n = 11,088), chronic obstructive pulmonary disease (COPD; n = 8495), pneumonia (n = 23,719), or stroke (n = 14,293). Measures. Risk-adjusted in-hospital mortality, early postdischarge mortality (between discharge and 30 days after admission), and 30-day mortality. Results. Risk-adjusted in-hospital mortality declined significantly for all conditions except stroke and GIH, with absolute declines ranging from –2.1% for COPD to –4.8% for pneumonia. However, the mortality rate in the early postdischarge period rose significantly for all conditions except COPD, with increases ranging from 1.4% for GIH to 3.8% for stroke. As a consequence, the 30-day mortality declined significantly only for CHF (absolute decline 1.4%, 95% CI, −2.5 to −0.1%) and COPD (absolute decline 1.6%, 95% CI, −2.8–0.0%). For stroke, risk-adjusted 30-day mortality actually increased by 4.3% (95% CI, 1.8–7.1%). Conclusion. During Cleveland’s experiment with hospital report cards, deaths shifted from in hospital to the period immediately after discharge with little or no net reduction in 30-day mortality for most conditions. Hospital profiling remains an unproven strategy for improving outcomes of care for medical conditions. Using in-hospital mortality rates to monitor trends in outcomes for hospitalized patients may lead to spurious conclusions.